frequent wakings in first hour(s) of sleep

[rdavis]

Hey all. I posted this question on another forum this week, but wanted to get all of your opinions as well.

I've been on therapy for about 4-ish months now. After I got adjusted, the first two months were absolutely flawless. I had AHIs around .2 or .5 on a pretty regular basis.

In the last month or two, my AHIs have crept up to around an average of 2. This wouldn't bother me except...the vast majority of them happen within the first 1-2 hours of sleep and lead to frequent wakings! I am tired of jumping awake, feeling the need to pull in a big breath, for two hours before finally drifting off. That's what I got on CPAP therapy to fix, and it was fixed until recently! I'm frustrated, because I can't figure out what changed from 2 months ago.

Although I have OSA, the machine is flagging hardly any of these events as obstructive...most are either hypopnea or clear airway events, with maybe one or 2 true OSA events per night. I've heard that auto-adjusting pressure on the machines can cause CSA events...could this be what's going on?

Also, any advice on how to talk to my doctor about this would be great. Because my overall, average-for-the-night AHI events aren't rising above 5 it's not flagging my doctor's concern. I use a program on my home computer to read my CPAP card data in detail, but doctors don't expect you to come in with that level of knowledge about what's going on, and they don't seem interested in answering in-depth questions about it (or even looking at it as closely as I am).

[robysue]

Although I have OSA, the machine is flagging hardly any of these events as obstructive...most are either hypopnea or clear airway events, with maybe one or 2 true OSA events per night. I've heard that auto-adjusting pressure on the machines can cause CSA events...could this be what's going on?

We don't have any idea what machine you are using or what pressures you are using. We need that information before we can try to answer this question.

I use a program on my home computer to read my CPAP card data in detail, but doctors don't expect you to come in with that level of knowledge about what's going on, and they don't seem interested in answering in-depth questions about it (or even looking at it as closely as I am).

Can you share some of your data with the forum? That's the only way we can give you informed opinions of what might be going on during those first couple of hours of sleep.

[rdavis]

I use a PR System One REMstar Auto with A-Flex, pressure settings 8-15. I use the SleepyHead software to read my results.

I'm having trouble uploading screenshots of my data to the web so that I can post the URL on here, but I will definitely keep trying tonight.

[Pugsy]

How to post images so we can see what you are seeing is explained here along with examples of what we like to see.
viewtopic/t103468/Need-help-with-screen-shots.html
https://sleep.tnet.com/reference/tips/imgur

[rdavis]

Here are links to a couple of screen shots of nights when I had this problem.

http://i.imgur.com/MdpISLM.png

http://i.imgur.com/11zdS3S.png

[robysue]

rdavis,

Thanks for posting the data.

You asked

Although I have OSA, the machine is flagging hardly any of these events as obstructive...most are either hypopnea or clear airway events, with maybe one or 2 true OSA events per night. I've heard that auto-adjusting pressure on the machines can cause CSA events...could this be what's going on?

I don't think the APAP is causing the apneas that are classifed as Centrals. The pressure increases in the data you posted are minimal increases, and most of them are nothing more than the test pressure increases from the PR search algorithm. And your pressure stays below 9cm for most of the night and you only very occasionally hit pressures above 10cm: Your pressures are AT or BELOW 10cm for at least 95% of the night since your 95% pressure levels are less than 10cm. Most of the time when APAPs might be a culprit in therapy-induced central apneas, the pressure is above 10cm for long periods of time and the CAI is typically above 5.0.

But it is clear that there's some weirdness going on near the beginning of these nights. You write:

This wouldn't bother me except...the vast majority of them happen within the first 1-2 hours of sleep and lead to frequent wakings! I am tired of jumping awake, feeling the need to pull in a big breath, for two hours before finally drifting off.

It looks like you are dozing or only very lightly asleep for the first hour or so of the night when the events are happening. In that case the events might be transitional (and might not be scored on a full in-lab sleep test) or they might be wake breathing being misscored as sleep disturbed breathing. On the night of March 7, there's another cluster of events in the middle of the night that takes place in a short session and the beginning of the session that follows the short session. Because of the length of the short session, I would suspect that again you were very restless and not fully asleep during that session, and that would imply that again this cluster of events might be sleep transitional or misscored wake breathing. Once the cluster of events ends, the rest of the night looks pretty clear.

So I'll end with some questions for you: Are you finding it harder to fall asleep with the PAP machine now? Are you lying in bed dozing lightly at the beginning of the night? Do you think you're falling asleep very briefly and then jerking awake (just as you're starting to really get to sleep) and then finding it very difficult to get back to sleep?

If you are spending an hour or more lying in bed awake (or very lightly dozing) and finding it hard to finally fall asleep, you might want to get up after trying to get back to sleep for 15-20 minutes (or whenever you start to get antsy, nervous, or uncomfortable) and doing something restful and sleep inducing in a different room. When you start to feel very sleepy again, go back to bed and mask up. You might find it much easier to get into a sound, continuous sleep once you return to bed.

[rdavis]

Thanks for the response! In answer to your question:

So I'll end with some questions for you: Are you finding it harder to fall asleep with the PAP machine now? Are you lying in bed dozing lightly at the beginning of the night? Do you think you're falling asleep very briefly and then jerking awake (just as you're starting to really get to sleep) and then finding it very difficult to get back to sleep?

Yes, I am definitely just in a doze state during the first hour or so. I usually go to bed pretty sleepy, but often can't get down into sleep because these frequent wakings pester me until I get frustrated and more awake. It's also become a problem with naps--I can't settle down into a nap with the Pap machine, either.

When I first started my therapy, I would put the mask on and be out like a light in the first few minutes. That was when I had really low AHI scores, like an average of .5 per night. I can't figure out if I've gotten less sleep-deprived, and therefore sleeping lighter at first and scoring more wakeful breathing--or if something with my ahi events really is changing, causing me to not be able to fall asleep. The reason I suspect the latter is because my sudden wakings are often accompanied by a big, long breath that I feel the need to draw the instant I'm awake.

[robysue]

Thanks for the response! In answer to your question:

So I'll end with some questions for you: Are you finding it harder to fall asleep with the PAP machine now? Are you lying in bed dozing lightly at the beginning of the night? Do you think you're falling asleep very briefly and then jerking awake (just as you're starting to really get to sleep) and then finding it very difficult to get back to sleep?

Yes, I am definitely just in a doze state during the first hour or so. I usually go to bed pretty sleepy, but often can't get down into sleep because these frequent wakings pester me until I get frustrated and more awake. It's also become a problem with naps--I can't settle down into a nap with the Pap machine, either.

The wakeful breathing is leading to the machine misscoring normal wakeful breathing patterns as events. In other words, my guess is that your true AHI is still down around 0.5, but you are lying awake or semiawake and the machine is misscoring the wakeful and semiawake breathing patterns.

I also think you are now so aware of your breathing patterns when you lie down in bed that your brain is now noticing and waking up if you happen to have a perfectly normal pause in breathing as you transition from wake to sleep. And, by the way, these normal transitional pauses are NOT scored on a typical in-lab sleep test, but your machine can't tell you are transitioning from wake to sleep. And most of the time a CPAP machine will score one of those normal transitional pauses in breathing as a central apnea because the airway is NOT obstructed---the transitional pause is caused by a less than perfect hand off of breathing control between the voluntary nervous system (which controls wake breathing) and the autonomous nervous system (which controls sleep breathing).

When I first started my therapy, I would put the mask on and be out like a light in the first few minutes. That was when I had really low AHI scores, like an average of .5 per night. I can't figure out if I've gotten less sleep-deprived, and therefore sleeping lighter at first and scoring more wakeful breathing--

If I had to bet, I would bet that you are now less sleep deprived now. And that's (part of) why you're now taking a longer time to fall asleep. Pre-CPAP how long did it take you to get fully asleep? If you've always taken a long time to fall asleep, then my guess is that you're over the severe sleep deprived stage and now hat you've made up your sleep "debt," your sleep is returning to a more "normal for you" pattern, that unfortunately includes a longer than desired latency to sleep. And with your increased awareness of your breathing patterns, your brain is noticing every small glitch in your breathing as your body is trying to transition from wake to sleep, even though the "events" are perfectly normal sleep transitional pauses in breathing.

or if something with my ahi events really is changing, causing me to not be able to fall asleep. The reason I suspect the latter is because my sudden wakings are often accompanied by a big, long breath that I feel the need to draw the instant I'm awake.

I think that your sensation of waking with a sudden need for a big, long breath is just being caused by an over awareness of your breathing patterns. One big difference between normal sleep breathing and normal wake breathing is that normal sleep breathing is typically quite a bit shallower as well as much more regular than normal wake breathing. When your breathing control is handed back to the voluntary nervous system because you just woke up, it's typical to take some much deeper breaths than the normal sleep breaths that preceded the wake.

If you don't see what I'm talking about, it would be useful for you to zoom in on one cluster of the central apneas that occur during the first session and also zoom in on the area just before a clear wake when you turn the machine off. Post that data and I'll see if I can show you what I'm talking about in your own data.

[rdavis]

This all makes a lot of sense, robysue!

So I guess the question is, what's a good way to relax with the CPAP and unwind my brain from needing to be so hyper-aware of it? Would welcome advice from anyone who has some great techniques for CPAP relaxation.

[49er]

This all makes a lot of sense, robysue!

So I guess the question is, what's a good way to relax with the CPAP and unwind my brain from needing to be so hyper-aware of it? Would welcome advice from anyone who has some great techniques for CPAP relaxation.

rdavis,

I listen to podcasts to fall asleep. I fall asleep very fast so what I listen to doesn't really matter. But in your case, perhaps something like listening to a guided imagery recording might be helpful?

Best of luck.

[robysue]

This all makes a lot of sense, robysue!

So I guess the question is, what's a good way to relax with the CPAP and unwind my brain from needing to be so hyper-aware of it? Would welcome advice from anyone who has some great techniques for CPAP relaxation.

It took me a very, very, very, very long time to get to the point where I was NOT be so hyperaware of everything CPAP-related that I could fall asleep rather quickly with the mask on. For the first 8 months of PAPing, putting my mask on at night was like drinking a shot of triple-strength expresso: No matter how sleepy and tired I was, masking up brought my brain to FULL AWAKE and ALERT mode. It was an awful experience.

For most people I think learning to ignore the physical stimuli from the machine and learning to not be so conscious of your own breathing is just a matter of practice. Giving your mind something to distract it from the CPAP-stuff can help. Like 49er, I find that having something relaxing and soothing to listen to as I fall asleep helps. In my case, it's a long playlist of Gregorian chants that plays on my iPod via speakers all night long at low volume. (My brain wakes up too much if I try to listen to something that has English in it.)

But I also have to be pretty strict about all aspects of my sleep hygiene in order to fall asleep rather quickly with my BiPAP on: I need to maintain a pretty consistent wake up time all seven days; I've also had to give up caffeinated drinks; getting some outdoors exercise helps; and I tend to go to bed only when I'm very,very sleepy. But even with the strict sleep hygiene, I sometimes do need to take an Ambien to get to sleep at night.